Fussy Baby Network® Oakland Strengthening

Connections AIA-September 11, 2011Mary Claire Heffron, PhD, Clinical Director

Children’s Hospital & Research Center OaklandEarly Intervention Services

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Age in MonthsGray et al, 2004

Admissions to ER for Infant Crying

33% had diagnosis of colic/crying

Fussy Babies in the ED

Who are fussy babies?

All Babies Cry

Crying as a Regulatory Function

• Increases lung capacity at birth• Increases motor activity• Helps regulate temperature• Triggers attachment

system/social interaction

Lester, 2006

What is it like to hear a baby cry inconsolably?

Normal Crying Curve

• Peaks at 4-6 weeks• First documented in

Brazelton’s practice• Replicated 15 times• Across cultures

12 weeks

6 weeks

Barr, Konner, Bakeman, & Adamson, 1991; Brazelton, 1962; St. James-Roberts, Bowyer, Varghese, & Sawdon, 1994

Brazelton, 1962

“The Witching Hour”

Large difference between infants

Brazelton, 1962

Crying Curve for Premature Babies

• Timing of crying peak is same as full-terms– 4-6 weeks corrected

age • Quality of crying may be

different than full-terms• “He never cried in the

nursery”

Definitions• Excessive crying: more than average amount of

crying • Colic: excessive crying plus sudden onset, more

aversive acoustical qualities, physical signs, more inconsolability (Lester et al, 1990)

• Persistent crying: crying past “cry curve” months (past 4 months)

• FBN Fussy Baby: any baby from birth to one year whose parent feels is difficult for him/her to console, feed, or help sleep

Wessel’s Rule of 3s for Colic

• Rule of 3s – More than 3 hours/day– More than 3 days/week– More than 3 weeks

• No single known cause

Wessel, 1954

Colic is Not Linked to:

• Birth order• Gender• Feeding style• SES• Colic can occur in healthy

babies, in spite of excellent parenting

Excessive Crying Plus:

• Sudden onset– Unpredictable

• Cry quality– Higher pitch, reaches peak

quickly– Like a pain cry

• Physical signs– Clenched fists– Grimace/flushing– Gas/distention

• Inconsolable“Late afternoon fist-shaking

rage”

Lester, Boukydis, Garcia-Coll, & Hole, 1990

How Long does Colic Last?

Begins early:• 100% by 3 weeks

End varies:• 50% by 2 months• 80% by 3 months• 90% by 4 months

Weissbluth, 1998

Different pathways to excessive crying

• Immaturity of GI tract• Cow’s milk/lactose

intolerance• Sensory thresholds• Transient regulatory problem• Abnormal sensitivity of CNS• Prenatal influences• Parent/child relationship

distress

Evaluation and treatment by maternal-infant mental health specialistMaternal psychotherapy

Reflux medicationSmaller, frequent mealsUpright positioningThickening feeds

Maternal dairy elimination if breastfed. Formula change to soy-based or elemental formula

Evaluation and treatment by medical professionals

Probiotic foods or supplementsTargeted antibiotics

Simethicone (Mylicon)ChamomileGripe water Dill oil, Fennel oilDicyclomine (Bentyl)

Swaddling, Side positioning, Shushing, Swinging, SuckingEnvironmental dampeningInfant massage / touchChiropractic manipulation

Maternal- Infant

DistressRegulatory problems,

neurological hyper-

sensitivity

Immaturity of the digestive

system Excessive gas

Crying of normal

development

Temper-ament

Colic

Bacterial over

Growth -imbalance

Underlying medical

condition or infection

Milk protein allergy

Reflux

Excessive Crying in Infancy

Underlying Medical Reasons

– Reflux

– Milk Protein Allergy

– Serious Infection (rare)

Gastroesophageal Reflux & GERD• Spitting up is a normal part of growing up as a baby• Most babies have reflux, with peak symptoms around

4 months of age, and resolution by 12 months.• In about 8% of babies, reflux results in concerning

symptoms, and we then assume that the infant suffers from gastroesophageal reflux disease, or GERD.

• GERD is defined as chronic symptoms or mucosal damage produced by the abnormal reflux in the esophagus.

• If the reflux reaches the throat, it may be called laryngopharyngeal reflux disease.

Gastroesophageal Reflux

•Lower esophageal sphincter (LES) is a muscle between the esophagus and the stomach•LES matures at 6-7 weeks•While immature, it does not close tightly, so feedings can go in a reverse direction, from stomach to esophagus

Mechanisms of Reflux

• Maturation, length and angle of LES affect reflux• Breathing (Inspiration and expiration) trigger

contraction of different portions of LES • Gastric distension (over feeding) and altered angle of

LES (flexed position) can increase reflux

When to Suspect GERD in an Excessive Crier

• Crying that is worse around feeding

• Frequent spitting up that seems uncomfortable

• Refusing feeding

• Trouble with weight gain

• Back arching (right)

• Coughing, choking, gagging

• Breathing difficulty

Regulatory Imbalance

• Imbalance between excitatory (arousing) processes and inhibitory (calming) processes

• Imbalance impedes infant’s regulation of stable sleeping and waking states and smooth transitions between states. The underlying cause is not known.– Sucrose hypothesis: central self-soothing mechanism is not

developed– GO systems (sympathetic nervous system) develops before

SLOW systems (parasympathetic)– Transient immaturity or temperament– Prenatally acquired constitutional factors

Lester, Boukydis,Garcia-Coll, Hole, & Peucker, 1992; Papoušek & Papoušek, 1984

Infant Sensitivities

• Prematurity• Drug exposure• Sensitive sensory system

Psychosocial Distress

• Perinatal Mood Disorder• Birth trauma • Limited family resources • Parental conflict

What Stresses Parents the Most• Prolonged length of cry

bouts • High intensity of cry

(high cry to fuss ratio)• Cry not reduced by

extra carrying• Resistance to soothing

which makes parents feel out of control

St. James Roberts, 2007

Photo courtesy of Ruth Fremson/The New York Times, 2008from: http://well.blogs.nytimes.com/2008/09/05/delivery-method-affects-brain-response-to-babys-cry/#more-511

Crying, Colic, andParental Perceptions

“The actual duration of crying at a given moment seems to be less relevant than the parent’s perception of the crying of their

infant in the long term.” Reijneveld et al, 2004, p. 1342

Cultural Context of Crying

• How does culture perceive crying?– Positive– Negative

• What strategies are used in various cultures?– Distal caregiving– Proximal caregiving

How would your grandma calm a fussy baby?

Proximal Caregiving

• Babies communicate through movement and cries

• Mothers sense babies’ arousal through body signals and soothe before crying beginsLester, 2006

Distal Caregiving

• Cry now used to call for basic care

• Have longer crying bouts• May have earlier

consolidation of sleep

Why worry about fussy babies?

• Risk for child behavior/development problems• Risk for parent-child relationship problems• Risk for child abuse• Risk for family stress and maternal depression

Risks to Behavior & DevelopmentSevere colic/persistent excessive crying in infancy past 5

months has been linked to the following child outcomes:• Motor, language, and cognitive delays • Behavioral problems (“temper tantrums”)• Negative reactivity (“fussiness”)• Sleep disorders• Feeding problems• Hyperactivity

DeGangi et al., 2000; DeSantis et al, 2005; Kries, Kalies, & Papousek, 2006; Papousek & von Hofacker, 1998; Rautava et al., 1995; Savino et al., 1995; Wake et al., 2006; Wolke, Rizzo, & Woods, 2002

Risks to Behavior & Development• Infant cry, sleep, & feeding problems associated with

externalizing behavior and ADHD across 22 longitudinal studies, particularly in families with multiple risks

• 75% of babies babies seen in Brown University colic clinic demonstrated some degree of atypical sensory processing between 3-8 years of age

• Hours of fussing—not crying—were associated with less efficient skills in sensory processing, coping, and externalizing behaviors

Desantis, Coster, Bogsby, & Lester, 2005; Hemmi, Wolke, Schneider, 2011

Risk for Child Abuse

Crying DurationShaking Baby Cases

Age in Weeks

2.75 hours

Barr, Trent, & Cross, 2006

Infant Crying & SBS

Lee, Barr, Catherine & Wicks, 2007

Risk for Maternal Depression • “Double Whammy”

of Infant Colic and Maternal Depression

• 46 % of mothers seen at Brown University Colic Clinic had moderate to high depression

Maxted et al., 2005

Maternal DepressionIn mother• frequent crying• appetite change• sleep problems• moderate to high anxiety• panic attacks• feeling unable to cope, worthless,

despair, guilt• sluggishness that interferes with

childcare• expression of little positive emotion

with infant• fear of harming child or self

In infant• poor eye contact• unpredictable sleeping and/or

eating patterns after 4 months• constricted affect• difficult to comfort or soothe• developmental delays

Clark, 1994; 2003

Parents ask:“Where is the finish line?”

“You think it is never going to end…”

Negative emotions• Wishing infancy away• “ It’s supposed to be bliss…• I just want it to be over.”• Progression of emotions• Overwhelmed• Angry• Guilty“Do you ever get mad at her?…feel like you’re going to hurt her?”

Family Impact

• Disrupted lives• Criticism and social

isolation• Search for diagnosis• Maternal depression• Parental conflict• Parent-infant relationship

distressLong & Johnson, 2001; Maxted et al., 2005; Wake et al., 2006

“No one said it would be this hard..”

• Disrupted daily routines-“Just doing the simplestthings…it’s just not possible”

• Disrupted personal lives-“You read about stress in the marriage. This is the stress in the marriage”

• Disrupted social lives-Now that we have a baby, we can’t even leave the house”

Criticism and Social Isolation• Family criticism: “If only you would..”

• Parental guilt: “I’m not hurting her, I swear…”

• Social isolation: “I feel so alone and I can’t take her any where”

Categories of Need for Fussy Baby Oakland

• Emerging developmental differences• Medical concerns• Emerging parent child relationship concerns• Family-Baby Stress • Parental mental health concerns • High risk family (more than 3 risk factors)

Age range of infants

57%

24%

13%

3% 3%

0-3 months

4-6 months

7-9 months

10-12 months

Did not report /missing

Screening for Depression & Anxiety

Use of focused questions:• During the past month, have you often been bothered

by feeling down, depressed or hopeless?• During the past month, have you often been bothered

by little interest or pleasure in doing things?• On a scale of 1 to 5, how stressed do you feel about

your baby’s crying/sleeping/feeding?

Worry Scale

Parents’ Two Worries:

• Is my baby alright?

• Am I a good enough parent?

T. Berry Brazelton, MDAmerica’s Pediatrician

Supportive interventions which embrace a bio-psychosocial perspective and which focus on the baby, parents, and parent/baby/family relationships can build competence, decrease stress/risk, and support healthy development

Gilkerson, Gray, Mork, 2005; Papousek, 2007; Maldonado, & Garcia, 1996; Keefe, et al., 2006 ; Maxted, et al., 2005

Help From a Dual Perspective

1. Help parents in the now moment with their urgent concern

2. With your eye on their future

• Parent’s confidence • Parent’s view of child• Relationship

Fussy Baby Network Approach

• Engages families around feeding, sleeping, crying and regulatory concerns

• Three goals:– Increase parental confidence– Strengthen parent-child

relationship– Promote healthy development

of parents and infants Photo courtesy of: http://images.sciencedaily.com

PRIME-MD PHQ Responses

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Maternal Depression

Fussy Baby Network Family Feedback Survey

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Response Means

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How distressed did you feel about your FussyBaby issue?

What was your distress level when yourinvolvement with the FBN ended?

To what extent do you feel that the FBN helpedyou cope with your distress?